Outcome of home haemodialysis patients: a case-cohort study

Abstract

Background. Randomized, controlled comparisons between home haemodialysis (HHD) and centre haemodialysis (CHD) have not been performed to date. Reported survival benefits of HHD as compared with CHD from uncontrolled studies have been attributed largely to patient selection. Methods. In order to minimize a selection bias, we have compared the outcome of our HHD and CHD patients with a nested case-cohort study. For each patient trained for HHD at our dialysis centre between 1970 and 1995 (n ¼ 103), a corresponding match was searched from the CHD patients by retrospective chart analysis. The pairs were matched for sex, age (±5 years), time of dialysis therapy onset (±2 years) and renal disease category. For 58 of the 103 HHD patients, a corresponding matched CHD patient was identified. Both treatment groups had the same mean age (50±13 years) at dialysis onset and were comparable with respect to the Khan comorbidity index, prevalence and duration of hypertension, smoking habits, history of myocardial infarction, stroke and peripheral vascular disease. In both groups, 50% of the patients were transplanted during the observation period. Results. HHD patients were hospitalized less often and tended to have fewer operations as compared with CHD patients. Survival was significantly longer in HHD as compared with CHD. Five, 10 and 20 year survival rates were 93 (n ¼ 55 patients at risk), 72 (41) and 34% (11) with HHD and 64 (38), 48 (26) and 23% (4) with CHD, respectively. This survival difference persisted after adjusting for predictors of mortality, i.e. age at onset of dialysis, year of start of dialysis therapy and Khan comorbidity index. Conclusions. HHD offers a cheap and valuable alternative to CHD, with no apparent disadvantages.

Utilization and Outcome of ‘Out-of-Center Hemodialysis’ in the United States: A Contemporary Analysis

“…We found that a similar relative risk of death between the PD patient and out-of center patients. In contrast to previous studies [3,5,10,13,14], we found no consistent association between out-of-center HD and better patient survival as compared with in-center HD. In fact, the relative risk of death among patients initiating out-of-center HD was significantly higher compared to those initiated on in-center HD.…”

“…Home hemodialysis (HD) was first introduced in 1964 [1], and its use in the United States peaked in the 1970s [2] when 40% of prevalent patients with end-stage renal disease (ESRD) were treated at home [3]. Unfortunately, the utilization of home HD subsequently declined due to reimbursement issues, complicated HD technology, lack of home HD expertise and training programs, and the concept that adequate dialysis could be achieved with conventional HD [4,5,6].…”

“…Home HD has been linked to improved outcomes [9,10,11,12] including better patient survival [3,5,10,13 ]lower costs [15,16], and enhanced quality of life [17]. However, much of this information is derived from small studies published in the late 1980s or early 1990s and may not reflect contemporary practice.…”

Choosing Home Hemodialysis: A Critical Review of Patient Outcomes

“…Studies on mortality and survival had the highest quality score of all outcome data assessed in this review (Table 2; score: 17 out of 31), and included one randomized controlled trial [2] and 9 retrospective or prospective observational studies [3-11], an analysis of an observational study [12], a post-trial observational study of the long-term effects of a randomized controlled trial [13], and a recently published matched-cohort study [14]. Studies predominantly reported positive (9) effects of HHD on mortality or survival compared to ICHD; 2 studies showed negative or no effects.…”

Prescriptions for home hemodialysis

“…29 The ability to teach patients to perform their own HD at home has been associated with improved survival and quality-of-life outcomes during traditional home HD. 31,32 Therefore, it is still a worthwhile exercise to teach patients to dialyze at home even if they are only willing to use a standard HD prescription.…”